Provider Demographics
NPI:1710311030
Name:GRAY, JOAN M (HIS)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:GRAY
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 GALLOWAY ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-3467
Mailing Address - Country:US
Mailing Address - Phone:715-831-8966
Mailing Address - Fax:715-831-8968
Practice Address - Street 1:218 ISLAND ST
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-2351
Practice Address - Country:US
Practice Address - Phone:715-726-0931
Practice Address - Fax:715-726-1085
Is Sole Proprietor?:No
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1397-60237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist